What is Diabetes Mellitus Type 2?Statistics on Diabetes Mellitus Type 2Risk Factors for Diabetes Mellitus Type 2Progression of Diabetes Mellitus Type 2Symptoms of Diabetes Mellitus Type 2Clinical Examination of Diabetes Mellitus Type 2How is Diabetes Mellitus Type 2 Diagnosed?Prognosis of Diabetes Mellitus Type 2How is Diabetes Mellitus Type 2 Treated?Diabetes Mellitus Type 2 ReferencesDrugs/Products Associated with Diabetes Mellitus Type 2 What is Diabetes Mellitus Type 2?
Type 2 Diabetes Mellitus is a chronic metabolic syndrome defined by resistance to the hormone insulin. This leads to inappropriate hyperglycaemia (increased blood sugar levels) and deranged metabolism of carbohydrate, fats and proteins. Insulin is a key metabolic hormone secreted by the pancreas. Insulin exerts its actions in the liver and peripheral tissues such as muscle and fat. In type 2 diabetes mellitus, relative insulin deficiency usually occurs because of resistance to the actions of insulin in muscle, fat, and the liver. This abnormality results in decreased glucose transport in muscle, increased liver glucose production, and increased breakdown of fat.
Type 2 diabetes mellitus is also known as Non Insulin Dependent Diabetes Mellitus (NIDDM). This name is no longer used as some patients with type 2 diabetes mellitus do require insulin treatment in advanced stages.
Statistics on Diabetes Mellitus Type 2Diabetes is a common condition in the Australian community. Approximately one quarter of Australians over the age of 25 years have diabetes or its precursor known as impaired glucose tolerance. Both these conditions increases one's risk of heart disease. Type 2 diabetes mellitus is by far the most common form of diabetes, accounting for 85-90% of all those diagnosed with diabetes mellitus.
Rates are increasing at alarming rates presumably due to the aging population and increased rates of obesity. Approximately 7.5% of Australians over the age of 25 years suffer from type 2 diabetes mellitus. Another 10% have a pre-diabetic condition called impaired glucose tolerance, and about a third of these patients will go on to develop overt diabetes within 10 years.
The incidence of type 2 DM increases with age. Most patients develop the disease after 40 years of age. Overall, males and females seem to be equally affected. The incidence of type 2 DM differs throughout the world, probably due to environmental, genetic and behavioural factors. People with Indian, Pacific Islander or Australian Aboriginal heritage are at particularly high risk of developing type 2 diabetes.
Children
While type 2 DM usually affects patients over 40 years of age, more and more younger people, even children, are now developing type 2 diabetes. The increasing number of young people who are overweight, with sedentary lifestyles, increases the incidence of type 2 diabetes mellitus in this age group.
Risk Factors for Diabetes Mellitus Type 2
In type 2 diabetes, peripheral resistance to the actions of insulin is combined with a pancreatic secretory deficiency of varying severity. Insulin resistance means the body is unable to take glucose (sugar) up into cells. Normally, the body would compensate for this by producing increased amounts of insulin, but in type 2 diabetes mellitus the pancreas cannot respond. This means not enough insulin is produced, and excess sugar remains in the bloodstream (hyperglycemia) instead of being taken up into cells and used for energy.
Type 2 diabetes is partly a genetic disease and partly a lifestyle disease. While some people have a genetic predisposition to diabetes, they may not actual develop the disease without 'lifestyle' triggers such as excess fat and sugar intake or inadequate physical exercise.
While there is no single cause for developing Type 2 diabetes, there are well-known risk factors. Some of these can be changed (avoidable) and some cannot (unavoidable).
Unavoidable risk factors
Avoidable risk factors
Type 2 diabetes mellitus may have an onset over several months, or be asymptomatic and be detected on a routine blood test. It is generally not recognised and diagnosed until the patient seeks health care for another problem.
Some common presenting symptoms of type 2 diabetes mellitus include:
Excessive thirst.Increased urine output (polyuria).Hunger.Weight loss or gain.Slow healing or frequent infections.Blurred vision.Dry eyesHeadaches.Numbness, tingling or burning of the feet (peripheral neuropathy).Without treatment patients may develop acute complications due to dehydration (HONKC, see below) and long-term complications will develop much more rapidly.
The main acute complication is hyperosmolar nonketotic coma (HONKC), sometimes also known as hyperosmolar hyperglycaemic nonketotic coma (HHNC). This is a condition that develops over several days in poorly controlled diabetes involving high blood glucose and potentially lethal secondary dehydration and electrolyte disturbances.
Long-term complications include:
Men are particularly susceptible to diabetic complications and often have higher rates of mortality than females.
Symptoms of Diabetes Mellitus Type 2Diabetes can be easily diagnosed if you present with the classic symptoms of:
Thirst.Polyuria- Passing urine often or waking at night several times to pass urine (nocturia).Fatigue.Hunger.Weight loss.However, many patients with diabetes remain assymptomatic for many years but are still subject to the damaging effects of high blood sugars. Unlike type 1 diabetes which tends to present acutely, type 2 diabetes presents gradually over several years.
At the time of diagnosis of type 2 diabetes, you may already have several complications of the disease, such as heart or eye problems. You may have noticed blurring of your vision, pins and needles in the feet (due to damage to the nerves) and recurrent infections.
Diabetes or impaired glucose tolerance may be detected on routine blood tests as part of a general health check-up or investigation for other symptoms or diseases. If you are obese, suffer from high blood pressure, have a family history of diabetes, have high cholesterol or come from a high risk population (e.g. Aboriginal background) it is important that you get tested for diabetes.
Clinical Examination of Diabetes Mellitus Type 2Your doctor will perform a careful examination mainly looking for the various complications of diabetes. This will include cardiovascular, neurological and retinal (eye) examinations. In the early stages of disease your examination may be completely normal, however as the duration and severity of disease progressed it is likely you will have some end-organ damage.
Your doctor will use a special device (called an opthalmoscope) to look at the back of your eye (retina). Here the doctor may see various degrees of diabetic retinopathy which basically represents damage to and leaking from the small vessels at the back of your eyes. Often cataracts (white opacities) may also be found in the lens. These develop because the excess sugar upsets the normal consistency of the lens. You may also have dry eyes.
Cardiovascular exam may reveal signs of heart failure due to ischaemic heart disease. You may have an abnormal heart rhythm or crackles at the base of your lungs from accumulated fluid. In addition, your blood pressure will be checked and your doctor may perform an ECG to detect any obvious ischaemic changes.
Leg examination may reveal diabetic ulcers (on pressure points in the feet) and peripheral vascular disease (poor peripheral pulses and circualtion), diabetic foot disease and trophic skin changes and skin infections. Your doctor will also test the nerves in your legs. You may have the classic 'glove and stocking' neuropathy which refers to reduced sensation in the distal portions of your limbs (i.e. where gloves and stockings are usually positioned). The neuropathy starts distally and progresses further up the limb as the condition worsens.
Your sensations of vibration (tested with a tuning fork placed on the bone) and propioception (recognition of joint space position, tested by wiggling your toe or finger with your eyes closed) tend to be affected first. In advanced cases you may have severe pain and impaired motor function.
Finally your doctor may request a urine sample to measure the amount of protein present. This reflects your kidney function as damaged kidneys tend to leak protein.
How is Diabetes Mellitus Type 2 Diagnosed?Type 2 diabetes mellitus is diagnosed when any of the following criteria are reached:
Symptoms of diabetes are present (increased urination, increased thirst or weight loss) with a random plasma glucose (RPG) level of >11.0mmol/LFasting plasma glucose (FPG) >7.0mmol/LOral glucose tolerance test (OGTT) 2 hour plasma glucose >11.1mmol/LPatients who do not reach these criteria may still be classified as having impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) on the basis of fasting blood glucose or oral glucose tolerance test results. These patients are at increased risk of developing type 2 diabetes mellitus.
Other tests which may be ordered include:
Glycosylated haemoglobin (HbA1c): this test is not used as a diagnostic or screening test for diabetes but may be used in the ongoing monitoring of diabetes. HbA1c reflects blood glucose levels over the past 2-3 months. Results >7% suggest poor blood glucose control and correlate with poor clinical outcomes.When a diagnosis of diabetes mellitus is first made, several tests are often ordered to check for organ function and exclude complications of diabetes. These may include:
Full blood count.Urea and electrolytes (potentially showing kidney impairment).Urinalysis to check for infection or protein loss through the kidneys.Liver function tests.Chest x-ray.ECG.Blood lipids (including cholesterol).Prognosis of Diabetes Mellitus Type 2Diabetes is associated with a significant long-term risk of early mortality and morbidity. Heart disease (heart attacks 3-5 times more likely), peripheral vascular disease (amputation 50 times more likely), and stroke (twice as likely) are the major causes of death in patients over the age of 50. In addition, diabetic eye disease and renal failure due to diabetic nephropathy are important causes of morbidity. In addition, renal failure is potentially fatal. However, several large trials have proven that the risks of long-term complications from diabetes can be reduced with good blood glucose (sugar) control.
The acute complication of hyperosmolar non-ketotic coma has a mortality approaching 50% due to the fact that it affects elderly patients with extensive medical problems. Hypoglycaemia due to inappropriate use of insulin or as a side-effect of medications is also potentially fatal.
General Cardiovascular Disease 10-Year Risk Calculator
This risk assessment tool is based on data from the Framingham Heart Study to estimate 10-year risk for general cardiovascular disease outcomes (coronary death, myocardial infarction, coronary insufficiency, angina, ischaemic stroke, haemorrhagic stroke, transient ischaemic attack, peripheral artery disease, heart failure). This tool is designed to estimate risk in adults aged 30-74 years of age without CVD at baseline examination. Use the calculator below to estimate 10-year risk.
PredictorsAge years MaleFemaleGender YesNoHave you been diagnosed with Type II diabetes?Are you a smoker?*Are you prescribed medication to lower your blood pressure? If you do not know the following blood pressure and cholesterol parameters ask your General Practitioner on your next visit.Systolic blood pressure** mmHg Total cholesterol*** mmol/L OR mg/dl HDL cholesterol**** mmol/L OR mg/dl ResultsSignificant (> 20%)Elevated (10–20%)
Mild risk (< 10%)
You have a significant risk of future cardiovascular disease requiring aggressive risk factor modification. You should see a health professional to ensure appropriate management.If diabetic, your sugar levels should be well controlled.Continue to avoid tobacco use or if you are a smoker, consider stopping this is something your General Practitioner can help you with.Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.Cholesterol levels should be assessed at least annually. Depending on your level, you might be advised to commence lifestyle changes or medication.Significant (> 20%)
Elevated (10–20%)
Mild risk (< 10%)
You have an elevated risk of future cardiovascular disease requiring risk factor modification. You should see a health professional to ensure appropriate management.If diabetic, you should aim for your sugar levels to be well controlled.Continue to avoid tobacco use or if a smoker, consider stopping this is something your general practitioner can help you with.Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.Cholesterol levels should be assessed at least annually. Depending on your level you might be advised to commence lifestyle changes or medication.Significant (> 20%)
Elevated (10–20%)
Mild risk (< 10%)
You have a mild risk of future cardiovascular disease, consider risk factor modification. You may like to see a health professional to ensure appropriate management.If diabetic, you should aim for your sugar levels to be well controlled.Continue to avoid tobacco use or if a smoker, consider stopping this is something your general practitioner can help you with.Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.Cholesterol levels should be assessed at least annually. Depending on your level you might be advised to commence lifestyle changes or medication.*For these purposes "smoker" means any cigarette smoking in the past month.
**Use current blood pressure, regardless of whether the person is on antihypertensive therapy.
***Total cholesterol values should be the average of at least two measurements obtained from lipoprotein analysis.
****HDL cholesterol values should be the average of at least two measurements obtained from lipoprotein analysis.
References:D'Agostino RB, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, Kannel WB. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 2008; 117: 743-753.National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002; 106: 31433421.Stancoven A, McGuire DK. Preventing macrovascular complications in Type 2 Diabetes Mellitus: glucose control and beyond. American Journal of Cardiology 2007; 99: 5H-11H.
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Male risk estimatePointsAgeHDLTotal CholesterolSBP Not TreatedSBP TreatedSmokerDiabetic-2 60+ PointsCVD riskHeart age (years)-3 or lessBelow 1% 8018 +> 30%> 80
Female risk estimatePointsAgeHDLTotal CholesterolSBP Not TreatedSBP TreatedSmokerDiabeticPointsCVD riskHeart age (years)-2 or less801615.9%>801718.5%>801821.5%>801924.8%>802028.5%>8021+>30%>80
More than 20 pointsSignificant risk of future cardiovascular disease requiring aggressive risk factor modification. You should see a health professional to ensure appropriate management.If diabetic, your sugar levels should be well controlled.Continue to avoid tobacco use or if you are a smoker, consider stopping this is something your General Practitioner can help you with.Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.Cholesterol levels should be assessed at least annually. Depending on your level, you might be advised to commence lifestyle changes or medication.10 to 20 pointsElevated risk of future cardiovascular disease requiring risk factor modification. You should see a health professional to ensure appropriate management.If diabetic, you should aim for your sugar levels to be well controlled.Continue to avoid tobacco use or if a smoker, consider stopping this is something your general practitioner can help you with.Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.Cholesterol levels should be assessed at least annually. Depending on your level you might be advised to commence lifestyle changes or medication.Less than 10 pointsMild risk of future cardiovascular disease, consider risk factor modification. You may like to see a health professional to ensure appropriate management.If diabetic, you should aim for your sugar levels to be well controlled.Continue to avoid tobacco use or if a smoker, consider stopping this is something your general practitioner can help you with.Blood pressure should be monitored closely. If elevated you should consider either lifestyle modification or appropriate medication. Your general Practitioner can advise you on this.Cholesterol levels should be assessed at least annually. Depending on your level you might be advised to commence lifestyle changes or medication.
This information will be collected for educational purposes, however it will remain anonymous.How is Diabetes Mellitus Type 2 Treated?
The first goals of treatment are to eliminate symptoms of hyperglycemia (high blood sugar), stabilise blood glucose, and restore normal body weight. The ongoing goals of treatment are to prevent or reduce long-term complications, and to allow the patient to live as normal a life as possible. 
A team approach is usually used in the management of diabetes mellitus. Team members may include a GP, diabetic specialist, diabetic educator, ophthalmologist, podiatrist, dietician and the patient themselves. These health professionals can help to monitor all aspects of the disease. Diabetic educators in particular are invaluable, providing you with information about nutrition, exercise, the management of diabetes during illness, and medication. They may also teach you skills such as home monitoring of blood sugar levels (BSLs).
BSL monitoring is now a simple and quick task, which can be accomplished by the use of a blood sugar monitor (pictured right). BSL monitors assess levels by analysing a drop of blood that has usually been obtained by a very quick finger prick and take only moment to give a result.
Monitoring of glucose control and regular follow-up is extremely important. Tests include glycosylated Hb (also known as HbA1c, a reflection of long-term blood glucose control), blood pressure, weight, plasma lipids, proteinuria (protein in the urine), kidney function, condition of feet and cardiovascular exam.
Regular education and counselling is also extremely important.
Lifestyle changes
Diet and exercise are key in the management of type 2 diabetes. In fact, most patients will notice an improvement in symptoms after just one month of lifestyle changes. Dietary changes focus on the ideas of weight loss and blood sugar regulation (that is, keeping the blood sugar levels relatively stable throughout the day, avoiding big peaks or troughs).
Some simple ideas include:
Eat healthy food, regularly spaced throughout the day - don't skip meals;Reduce the amount of fat in your diet;Avoid refined carbohydrates and sugars, replacing them with complex carbohydrates (such as wholemeal bread);Eat plenty of fruit and vegetables; andReduce or eliminating alcohol from the diet.It is recommended that you consume foods that have a low Glycaemic Index (GI) as these raise your blood sugar by much lower amounts.
Exercise is also extremely important in managing diabetes. 30 minutes of moderate activity on most days of the week is recommended. If you are not used to exercise, always take care when beginning a new exercise program, and see your health professional before you begin.
If you are significantly overweight or obese you may require additional treatments to help you lose weight. A variety of obesity treatments are now available including meal replacement programs, lifestyle changes, weight loss drugs and surgery (for the morbidly obese). You should discuss with your doctor whether any of these treatments are suitable for you.
Medications
If lifestyle modifications are inadequate to control diabetes, tablets are usually the next step. Metformin is usually the first line agent if you are overweight as it does not have the side effect of weight gain. Sulfonylureas (e.g. glibenclamide and gliclazide) are the tablets of choice in thin patients. Care must be taken in the latter case to avoid hypoglycaemia (low blood sugar).
You should be aware of warning signs of a hypoglycaemic attack including weakness, pallor, hunger, sweating, shaking, confusion, loss of concentration and blurred vision, and carry suitable sugar remedies. Metformin can have a serious side effect called lactic acidosis if you have impaired renal, liver or cardiac function. Your doctor will decide whether this medication is suitable for you and explain situations where metformin treatment may be dangerous.
Another oral hypoglycaemic agent is often added later on. Acarbose and newer drugs (rosiglitazone and pioglitazone) can also be used. Insulin may eventually be needed in poorly controlled diabetes, or when other treatments fail.
Diabetes Mellitus Type 2 ReferencesBraunwald, Fauci, Kasper, Hauser, Longo, Jameson. Harrison's Principles of Internal Medicine. 16th Edition. McGraw-Hill. 2005Cotran, Kumar, Collins 6th edition. Robbins Pathologic Basis of Disease. WB Saunders Company. 1999.Dunstan, Zimmet, Welborn, Sicree, Armstrong, Atkins, Cameron, Shaw, Chadban on behalf of the AusDiab Steering Committee, Diabesity & Associated Disorders in Australia- 2000. The Accelerating Epidemic, International Diabetes Institute, 2001.Hurst JW (Editor-in-chief). Medicine for the practicing physician. 4th edition Appleton and Lange 1996.Isley W, Oki J. 'Diabetes Mellitus, Type 2.' eMedicine, Web MD, 2006. Available at URL: http://www.emedicine.com/med/topic547.htm. (Last accessed 12/12/06).Kumar P, Clark M. Clinical Medicine. WB Saunders 2002 Pg 427-430.Longmore M, Wilkinson I, Torok E. Oxford Handbook of Clinical Medicine. Oxford University Press. 2001.Murtagh J. General Practice. 3rd edition. McGraw-Hill. 2003.Talley NJ, O'Connor S. Examination medicine. 5th edition. Churchill Livingstone. 2006.Coyne KS, Margolis MK, Kennedy-Martin T, et al. The impact of diabetic retinopathy: perspectives from patient focus-groups. 2004. Fam Prac; 21(4): 447-53. [Abstract]Watkins PJ. Retinopathy. BMJ. 2003; 326: 924-6. [Full Text]International Council of Ophthalmology. Diabetic Retinopathy (Initial and Follow up evaluation). 2010. [URL Link]American Diabetes Association. Physical Activity/Exercise and Diabetes. Diabetes Care. 2004; 27(s1): s58-s62. [Full Text]Huang ES, Brown SES, Ewigman BG, Patients perceptions of Quality of life with diabetes related complications and treatments. Diabetes care. 2007; 30(10): 2478-2483. [Abstract | Full Text]
Drugs/Products Used in the Treatment of This Disease:Actos (Pioglitazone hydrochloride)Amaryl (Glimepiride)Avandia (Rosiglitazone maleate)Diabex (Metformin hydrochloride)Diamicron MR (Gliclazide)Glimel (Glibenclamide)Glucobay (Acarbose)Glucophage (Metformin hydrochloride)Humalog Injection (vial) Humalog Injection (cartridge) (Insulin Lispro)Lantus (Insulin glargine)Levemir (Insulin Detemir (rys))Connect
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